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Published byAshlie Manning Modified over 9 years ago
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Endocrine investigation of a case of adrenal insufficiency
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Patient’s particulars Name XYZ Age 32 years Sex Male Occupation Serving sepoy (SSG) Address Muzaffarabad - Azad Kashmir Admitted to MH Rwp 03 Nov 2007
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Generalized weakness Darkened complexion Anorexia Weight loss Dizziness Frequent loose stools Vomiting 5 days 2 years Presenting complaints
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History of presenting complaints Apr 06 - Seconded to UN mission in Liberia Jul 06 First presentation: - Weakness, easy fatiguability, vomiting & loss of appetite - Reported to level 2 hospital (Liberia) - Conservatively managed - Reported several times with similar complaints
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History of presenting complaints (contd) Jan 07 - Reported again with aggravated complaints - Transferred to level 3 hospital (Liberia) - Worked up for adrenal insufficiency Mar 07 -Transferred to level 4 hospital (Ghana) for confirmation of the diagnosis - Plasma ACTH assay & MRI abdomen were performed - No medical records available - Advised tab prednisolone for 6 months - Rejoined his unit in Liberia
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History of presenting complaints (contd) Apr 07 - Repatriated - Rejoined active service - Continued tab prednisolone Aug 07 - Compliance declined & discontinued treatment
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History of presenting complaints (contd) Nov 07 - Reported to MH Rawalpindi with loose stools & vomiting - Darkened complexion - Weight loss 7 kg - Preference for salty foods No history of haemetemesis, melaena, jaundice, heat intolerance, palpitations, fever, haemoptysis, polyphagia or polyuria
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Past history Family history Personal history Dietary history Drug history Not contributory History (contd)
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General physical examination 2000 2007
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Pulse 96/min, regular Blood pressure 100/70mm Hg (supine) 30mm Hg postural drop (systolic) Temperature 98.4 0 F Respiratory rate 18/min Weight 52 kg General physical examination
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General physical examination (contd) Pallor Jaundice Dehydatrion JVP Not raised Thyroid Fundi Normal No visual field defects No evidence of proximal myopathy Absent Not palpable Mild
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Systemic examination Central nervous system Cardiovascular system Respiratory system Gastrointestinal system Unremarkable
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Provisional diagnosis Adrenal insufficiency
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Blood Counts: Haemoglobin 14.3 g/dL Total leukocyte count 6.0 x 10 /L Neutrophils 55% Lymphocytes 38% Monocytes 3% Eosinophils 4% MCV 82.3 fL Platelets 192 x 10 /L ESR 8 mm fall (end of 1st hr) 9 Investigations 9
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Investigations (contd) Plasma glucose fasting & post prandial Serum urea Serum creatinine Serum electrolytes - Na - K - Ca Within reference range Normal + + ++
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Investigations (contd) X-ray chest Sputum for AFB Mantoux test TB serology USG abdomen X-ray abdomen Liver function tests Normal No abnormality noted
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Investigations (contd) Serum cortisol 9.0 (5-25) µg/dL Plasma ACTH >1000 (8-79) pg/mL Serum TSH Plasma PTH Serum FSH Serum LH Within reference range
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Basal serum cortisol 8.1 µg/dL (5-25 µg/dL) Inj synacthen (synthetic ACTH) 250µg administered I/M Serum cortisol after 30 mins 8.77 µg/dL Serum cortisol after 60 mins 9.19 µg/dL Short synacthen test
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Investigations (contd) Autoimmune profile: Anti adrenal antibodies Thyroid microsomal antibodies Negative Antinuclear antibodies Contrast enhanced MRI abdomen Small sized adrenal glands with no calcification HIV serology Negative
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Final diagnosis Idiopathic adrenal insufficiency
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Inj ciprofloxacin 500mg I/V twice daily Replacement therapy: Tab prednisolone 10mg (morning) and 5mg (evening) Tab fludrocortisone 0.05mg once daily Management
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Follow up Appetite has improved Gained 4 kg of weight No postural variation in blood pressure
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